Reoperation For Infection Research Articles

Removal of infected arteriovenous grafts is morbid and many patients do not receive a new access within 1 year

ObjectiveInfection of a prosthetic arteriovenous graft (AVG), in patients who have many comorbidities and limited access options, is a feared complication. Our objective was to investigate our contemporary series of infected AVG operations and analyze perioperative and long-term outcomes. MethodsWe performed a retrospective analysis of AVGs removal, in the setting of infection, from 2005 to 2017 at a single institution. Procedures were classified as total excision if all graft material was removed, subtotal excision if small cuffs remained, and revision if a segment was removed and the graft was revised. Demographics, medical history, perioperative details, and follow-up data were collected. ResultsThere were 47 patients who underwent an operation for an infected AVG—forearm (27.7%), upper arm (63.8%), and femoral (8.5%). The mean age was 57.7 years and 59.6% were male. The average time from AVG placement to operation for infection was 20.4 months and 85.1% of grafts were placed at our institution. There were 33 patients (70.2%) who had a previous access before the infected graft. Patients with infected AVGs presented with bacteremia (57.4%), sepsis (36.2%), purulent drainage (55.3%), and bleeding at the graft site (31.9%). The majority of grafts (61.7%) were patent on presentation. There were patients 17 (36.2%) who had a fistulogram and 16 (34%) underwent an endovascular intervention within 90 days of graft excision. With regard to procedure type, 40.4%, 38.3%, and 21.3% of AVGs were treated with total excision, subtotal excision, and revision, respectively. Bacterial growth was present in 84.8% of specimens with the most common bacterial species being any Staphylococcus aureus (53.2%), methicillin-resistant S aureus (17%), coagulase-negative S species (10.6%), and Pseudomonas aeruginosa (8.5%). Postoperative intensive care unit admission occurred in 21.3% of cases. There were 25 postoperative complications that occurred in 17 patients (36.2%). The most frequent postoperative complications were nongraft site infections (28%) followed by graft-related events (16%). Mortality at 90 days and 1 year were 2.1% and 12.8%, respectively. Readmissions at 30 and 90 days were 30% and 55%, respectively. Reoperation for infection in the index limb occurred in 10.6% of patients—40% from those who had subtotal excision and 60% from those who underwent revision. New access was placed in 52% of eligible patients at 1 year. ConclusionsRemoval of an infected AVG is associated with high morbidity and resource use. Many eligible patients do not receive a definitive access within the first year of graft excision. Close follow-up is necessary to allow opportunities in reassessing for potential new access creation.

The Influence of Post-Operative Blood Glucose Management on Reoperation for Infection Following Total Joint Arthroplasty

The Influence of Post-Operative Blood Glucose Management on Reoperation for Infection Following Total Joint Arthroplasty

Success of Two-Stage Reimplantation in Patients Requiring an Interim Spacer Exchange

BackgroundSome patients undergoing a 2-stage revision for a periprosthetic joint infection require a repeat spacer in the interim (removal of existing spacer with insertion of a new spacer or spacer exchange) due to persistent infection. The objectives of this study are to (1) determine the factors associated with patients who receive a repeat spacer and (2) compare the infection-free survival (overall and stratified by joint type) of reimplantation in patients who did or did not receive a repeat spacer. MethodsFrom 2001 to 2014, 347 hip or knee 2-stage revisions that finally underwent reimplantation and had a minimum 2-year follow-up were identified. An interim spacer exchange was performed in 59 (17%) patients (exchange cohort). Patient-related and organism-related factors were compared between the exchange and non-exchange cohorts. Kaplan-Meier survival curves were performed to assess the success (absence of signs of infection, reoperation for infection, periprosthetic joint infection–related mortality) of both cohorts. ResultsPatients in the exchange group had higher comorbidity score (P = .020), prolonged time to reimplantation (P < .001), and higher prevalence of resistant organisms, though not statistically significant (P = .091). The 5-year infection-free survival rates were 64% (knee 62%, hip 64%) in the exchange cohort, and 78% (knee 77%, hip 78%) in the non-exchange cohort (P = .020). ConclusionsPatients requiring an interim spacer exchange were found to have more comorbidities, prolonged treatment period, and were more likely to be infected with a resistant organism. About one-third of such patients became reinfected within 5 years compared to only one-fifth of the patients without an interim spacer exchange.

Success rates, characteristics, and costs of articulating antibiotic spacers for total knee periprosthetic joint infection

BackgroundThe optimal type, characteristics, and success rates of articulating antibiotic spacers used during total knee arthroplasty (TKA) periprosthetic joint infection (PJI) have not been well defined in a single series. We sought to (1) determine the success rate for three unique spacer constructs and (2) evaluate any microbiological, surgical, or patient characteristics that would influence the success rate. MethodsWe retrospectively reviewed patients who underwent a two-stage exchange for a TKA PJI with a prefabricated spacer (PREFAB), home-made mold (MOLD), or autoclaved femoral component (AUTOCL). Patient demographics, microbiology data, amount of antibiotic in each spacer construct, postoperative course, and infection cure outcomes were evaluated. ResultsThe success rate for being infection free at final follow-up without the need for further reoperation for infection was 82.7% in the PREFAB group, 88.4% in the MOLD group, and 79.4% in the AUTOCL group (p=0.54). There was no clear statistical link between raw quantities of vancomycin and aminoglycoside in the spacer and a successful outcome. The surgeon's own intraoperatively created mold group had the lowest construct cost at a mean $1341.00±889.10 (p<0.0001) per construct, while the commercial cement molds had the highest mean cost at $5439.00±657.80 (p<0.0001). ConclusionsThere was no statistically significant difference in the success rates between the antibiotic spacer types. The surgeon's own intraoperative mold had the least overall associated cost.

Outcome of patients with chronic mesh infection following abdominal wall hernia repair

Mesh infection following incisional hernia repair has been reported at around 6-10%. The aim of this study is to assess the outcome of patients following treatment for chronically infected mesh after repair of an abdominal wall hernia. Data were gathered on all patients with chronically infected mesh following failed conservative management treated under the care of one surgeon between January 2004 and December 2010. This included patient demographics, reason for first operation, number of previous operations and the number of previous hernia repairs. In addition, the type of mesh removed was recorded as was the organism cultured from the wound. Patients were followed up in a clinic at 1month, 3months and 1year after surgery. 15 patients had 18 operations under general anaesthesia for infected mesh (10 partial and 8 complete mesh excisions). The interval between the last mesh implantation or abdominal operation and re-operation for infection was a median of 17months (range 7-49months). All patients who had complete mesh removal had complete healing of their wound at 3months compared with four in the partial excision group (P=0.011). At a median follow-up of 19months, only five in the complete and three in the partial excision group had complete wound healing (P=0.184). The outcome of patients treated for chronic mesh infection is unsatisfactory with high risk of recurrent herniation and development of further chronic abdominal wall sepsis; therefore, every effort should be made to prevent this problem in the first instance.

Infection Following Simultaneous Bilateral Total Knee Arthroplasty

Between 2000 and 2009, demographics, clinical characteristics, and infection details were compared among patients undergoing simultaneous BTKA (SBTKA), staged or UTKA. 2825 (16%) patients underwent SB, 1151 (6%) staged, and 13,983 (78%) UTKA. The overall infection rate following SBTKA (0.57%) was lower compared to staged (1.39%) or UTKA (1.1%) (P=0.01). The in-hospital infection rate was lower for the SB group (0.28% vs. 0.96% vs. 0.69%, respectively, P=0.01). The rate of late infections was comparable between the groups (0.32% vs. 0.43% vs. 0.43%, respectively, P=0.72). The rate of superficial infection was lower in the simultaneous cohort (0.28% vs. 1.04% vs. 0.87%; P=0.003). The overall rate of deep infection and reoperation for infection was similar among the groups. Among patients with late infection, age, gender, comorbidity score, time to infection, and most common organism isolated were not significantly different between the groups. Among infected patients after SB or staged TKA, 3 SB patients (18.75%), and 3 staged (20%) had bilateral involvement (P=1.0). Staged patients had more 2nd side infections, while simultaneous patients had more 1st side infections (P=0.02). Regression analysis showed that UTKA patients were 2.5 times more likely to develop in-hospital infection compared to SBTKA, while staged patients were almost 3.4 times more likely. Each additional hospital day increased the risk of late infection by 11.3%. SBTKA demonstrates an advantage over staged and maintains the safety profile of unilateral approaches with respect to infectious complications.

Clinical study on the repairing of Gustilo III B and III C open tibia fractures by bone fixation and tissue flap

Objective To investigate the choice of methods and time on the treatment of Gustilo type 11I B and type m c open tibia fractures by bone fixation and tissue flap repairing. Methods The clinic data of 156 cases of Gustilo Ⅲ B and ⅢC open tibia fractures were retrospectively studied. There were 102 males and 34 females, with average age of 34 years（range 14 to 68 years）. Ninety-eight cases were classified as Gustilo type ⅢB and 38 cases were type Ⅲ C in degree. In all cases, one hundred and thirteen were treated with one- stage external fixation, ninteen cases were treated with secondary bone fixation. Sixty-seven cases of all wounds were repaired by one-stage vascular pedicle skin flap. Seven wounds were repaired by one-stage free flaps with vascular anastomosis. Sixty-two cases were secondary repaired by different flaps after defect tissue under VSD （vacuum-sealing-drainage） treatment by 1 to several weeks, which contains 9 free skin graft, eleven muscle flaps based on posterior tibial artery perforator, thirteen flaps based on fibial artery perforator, fourteen gastroc- nemius falps and 15 cross-leg flaps. Results Wound of all cases were healed wholly. Primary union oc- curred in 121 cases, twelve vases healed after bone grafting for segmental bone defect. Three cases with delayed union healed after reoperation for infection that caused osteomyelitis and sinus tract. The period of bone healing was form 5 to 12 months. Conclusion The treatment of Gustilo Ⅲ B and Ⅲ C open tibia fractures by one- stage or secondary bone fixation and tissue flap repairing get their advantages and disadvantages, but one-stage bone fixation and tissue flap repairing was better where appropriate. Key words: Tibia frartures ; Gustilo type; Bone fixation; Tissue flap

Multi-center study of use of the Exeter stem in Japan: evaluation of 1000 primary THA

BackgroundThe Exeter stem was introduced to the Japanese market in 1996. Since then, owing to excellent clinical results, the number of stems used has increased year by year and more than 2000 stems were implanted in 2009. The objective of this study was to prove the efficacy of the Exeter stem for Japanese patients by evaluating the short-term results of four major dedicated hip centers. MethodsWe performed a retrospective study of clinical and radiographic results of 1000 primary total hip arthroplasties (THA) performed using the Exeter stem on 881 patients who were followed-up for at least 2years after surgery. The average age of the patients at operation was 62.3years (range 23–89years). Mean postoperative follow-up period was 4.0 (range 2–9) years. ResultsThirty postoperative complications were observed, including 9 infections, 14 dislocations, 5 cases of deep vein thrombosis, and 2 cases of sciatic nerve palsy. No symptomatic pulmonary embolization or femoral fractures were observed. Re-operations for infection and dislocation were performed in 8 and 6 hips, respectively. According to Barrack's classification, the postoperative cementing grade was judged as A for 735 hips, B for 246 hips, and C for 4 hips. At final follow-up, no radiolucent line was observed at the bone–cement interface. Cortical hypertrophy was observed in 9.5 % of cases in Gruen zones 2–6. Kaplan–Meier survival analysis predicted 100 % survival at 5years when a radiolucent line at the bone–cement interface of the femur was used as the endpoint, 98.8 % when re-operation was required for any reason. ConclusionsThis study revealed that excellent short-term results were achieved by fixing the Exeter stem with modern cementing techniques for primary THA in Japanese patients.

Obese Patients and Mechanical Circulatory Support: Weight Loss, Adverse Events, and Outcomes

Obesity and heart failure are increasingly common, but the outcomes, weight changes, and adverse events of patients with advanced heart failure and obesity on mechanical support is not well described. We retrospectively reviewed all non-underweight patients with durable mechanical support at a single institution from January 2000 until December 2008 and compared outcomes, weight change, and Interagency Registry for Mechanically Assisted Circulatory Support-defined adverse events between obese and nonobese patients. A total of 169 patients were included; 113 (67%) nonobese and 56 (33%) obese. Baseline characteristics, pump types, and implant duration were similar for both populations with the exception of more diabetes (61% vs 26%, p < 0.0001) and hypertension (61% vs 42%, p = 0.019) in the obese. Outcomes on mechanical support at 6 months were not different between groups. There was no significant difference between the nonobese and obese groups in the change in body mass index (-0.3 vs -1.0 mg/m(2), p = 0.29) over the duration of support. Obese patients, as compared with the nonobese, had higher incidence rates of sepsis (64.5% vs 34.7%, respectively, p = 0.006) and reoperation for infectious complications (34.2% vs 13.3%, respectively, p = 0.014). Obese patients also had a higher cumulative incidence of sepsis and reoperation for infection. Two-year posttransplant outcomes were not different in the obese and nonobese. Obese patients have similar outcomes on mechanical support, but at the cost of a higher cumulative incidence of sepsis and reoperations for infection; however, obese patients lose little weight while on mechanical support.

ORIGINAL RESEARCH—SURGERY: Antibiotic Coating Reduces Penile Prosthesis Infection

ABSTRACT Aim To evaluate the efficacy of a new antibiotic-coated (rifampicin + monocycline) penile prosthesis in prevention of bacterial adhesion and reduction of penile prosthesis infection. Methods In a retrospective analysis of medical records of men who had undergone implantation of American Medical Systems (AMS) inflatable penile prostheses between July 1990 and November 2003, we compared patients with AMS antibiotic-coated prostheses and patients with AMS nonantibiotic-coated prostheses. A total of 152 men aged from 27 to 79 years with erectile dysfunction underwent implantation of the AMS inflatable penile prosthesis. Fifty-eight patients received the antibiotic-coated prosthesis between July 2001 and November 2003, and 94 patients received the nonantibiotic-coated prosthesis between July 1990 and June 2001. Results In most cases infection was present; it was detected 1–2 days or up to 3–6 months after implantation. Complications including infection, which required surgical intervention, were observed in 15 patients of the nonantibiotic-coated prosthesis group (three reoperations for infection), and noninfection-related failure in five patients of the antibiotic-coated prosthesis group. In the nonantibiotic-coated prosthesis group of patients, time to infection ranged from 1 day to 6 months (mean 3.5 months). The antibiotic-coated prosthesis group of patients immediately after surgery and during the short- and intermediate-term follow-up had no infection of the penile prosthesis. Conclusions We suggest that the antibiotic locally delivered from the prosthesis coating might be an effective supplement for prevention of prosthesis-related infection in penile prosthesis surgery.

Fewer reoperations and shorter stay in the cardiac surgical ward when stabilising the sternum with the Ley prosthesis in post-operative mediastinitis.

Using the Ley prosthesis, a 0.5mm thick titanium alloy plate for stabilising the sternum, is a new method in the treatment of mediastinitis after open-heart surgery. We report a retrospective analysis of our experience with this device. One hundred consecutive cases of post-operative mediastinitis in the period 1992-1997 were reviewed. The primary procedure at reoperation for infection was as follows: 52 patients were treated with the Ley prosthesis and 48 patients underwent other conventional procedures. The choice of the surgical technique depended on the attending surgeon. The prosthesis was used more frequently in patients with sternal dehiscence (P<0.001) but otherwise patients' characteristics were similar in the two groups. As a control population for outcome data, 100 uninfected patients were matched with regard to operative procedure, age, sex and date of surgery. The median hospital stay was 48.5 days in the mediastinitis group vs. 14 days in the control group. The all-cause 90-day mortality in the mediastinitis group was 18% vs. 5% in the control group. The 52 patients treated with the Ley prosthesis had a median length of stay in the cardiac surgery ward for 29 days vs. 41.5 days in the mediastinitis group not treated with the prosthesis (P=0.013). However, when the total length of stay including hospitals outside the cardiac surgery ward was taken into account, the prosthesis did not reduce the length of stay. Only 8/52 patients treated with the prosthesis required further surgery vs. 23/48 patients who were not primarily treated with the prosthesis (P<0.001). The Ley prosthesis had no impact on mortality. The Ley prosthesis is a valuable adjunct to the treatment of mediastinitis after open-heart surgery. A shorter stay at the cardiac surgery ward and a reduced need for further surgical procedures were observed when using this prosthesis.

Twelve-year experience with glutaraldehyde-preserved porcine xenografts

Three hundred fifty-two patients underwent aortic (AVR) or mitral (MVR) valve replacement with a glutaraldehyde-preserved porcine xenograft from 1970 to 1980. Analysis of this series revealed the following information: hospital mortality, 11.6% (41/352); late mortality, 5.5% per patient-year (60/1,090.7); actuarial 5 year survival rate, 70%; incidence of thromboembolism and hemorrhage, 1.4% per patient-year (15/1,090.7); incidence of spontaneous degeneration, 1.1% per patient-year (12/1,090.7); and transvalvular gradient. AVR 16 mm Hg and MVR 4.6 mm Hg. These results compare favorably with results from other porcine xenograft series and with those reported for prosthetic valves. There is no apparent difference in the type of xenograft used with the exception that spontaneous degeneration occurred less frequently in mitral valves that had not undergone pressure fixation than in those that had. The use of flexible stents improved the ease of valve implantation but did not affect leaflet durability as anticipated. Calcification occurred randomly with no relationship to time of implantation. Reoperation was for spontaneous valve deterioration by calcification or collagen degeneration in 11 cases, paravalvular leak in 13 cases, and implantation of an undersized valve in four cases; there was one reoperation for infection. Results support the continued use of porcine xenografts and suggest that improved manufacturing techniques will reduce the incidence of spontaneous, sterile deterioration, which is the only serious drawback to routine use of the porcine xenograft.